Air traffic control and risk management need improvement on joint-operation airports
The Safety Investigation Authority has completed its investigation of the serious incidents in the vicinity of the Jyväskylä airport in the morning of 5 April 2019.
The incidents involved two wings of the Finnish Air Force (callsigns Spade 1 and Spade 5) that were returning from the Final 2019 flight operations exercise to the Jyväskylä airport. In the first incident, the Spade 1 wing had to take evasive action due to Patria Pilot Training Ltd’s general aviation aircraft OH-TPI that was in an airfield traffic pattern for a runway at the same time, flown solo by a flight cadet in training. The Spade 1 wing did not gain a visual of the aircraft at any point. The second incident occurred immediately after this, when the Spade 1 wing dispersed while avoiding the general aviation aircraft and flew through the Spade 5 wing as individual aircraft.
The incidents did not cause any personal injuries or material damage.
The Safety Investigation Authority issues four safety recommendations for the improvement of aviation safety and the prevention of similar incidents.
The first recommendation is related to ensuring the competence of air traffic controllers:
Although the current air traffic controller competence assessment system at ANS Finland complies with the procedure drawn up by the European Aviation Safety Agency , the system in place does not sufficiently ensure the maintenance of competence and routine required in the work of an air traffic controller, states Professor Veli-Pekka Nurmi, Executive Director of Safety Investigation Authority, Finland.
The Safety Investigation Authority recommends that the Finnish Transport and Communications Agency (Traficom) reassess the purposefulness and effectivity of the competence assessment process of Air Navigation Services Finland Oy.
Secondly, the Safety Investigation Authority recommends that the Finnish Air Force take into account in the ORM risk analysis for its exercises the air navigation risks related to the departures and returns of wings, and update the flight operation instructions for its exercises to conform with this risk management.
The return from the exercise area was considered to be a routine flight operation, although the vicinity of the airport is a safety-critical environment. The ORM risk analysis did not include a separate safety assessment of the departures and returns of the Final 2019 flight operations exercise. However, they are part of comprehensive training operations. The risks related to military aviation departures and returns should therefore be critically reviewed, particularly in joint-use airports also involving civilian traffic, emphasises Investigator-in-charge Janne Kotiranta.
Thirdly, the Safety Investigation Authority recommends that the Finnish Air Force develop clearly distinguishable aircraft callsigns for its exercises.
The Finnish Air Force uses radio callsigns with similar pronunciation in its training operations. In radio traffic, similar callsigns will cause confusing when traffic is busy. The risk of confusion is particularly emphasised on joint-operation airport with large volumes of traffic. Clear and easily distinguishable aircraft callsigns decrease mix-ups and thus increase aviation safety, states Investigator-in-charge Kotiranta.
The fourth recommendation of the Safety Investigation Authority is related to the positioning of air traffic control workstations and harmonisation of workstation ergonomics. Air traffic control operations, hardware and workstation ergonomics have differences between different joint-operation airports.
Fourthly, the Safety Investigation Authority recommends that Air Navigation Services Finland Ltd. prepare uniform instructions for the placement, hardware and workstation ergonomics for joint-operation airports.
Chief Air Safety Investigator Janne Kotiranta tel +358 2951 50703
Executive Director, Professor Veli-Pekka Nurmi, tel. +358 2951 50701